Current through Reg. 50, No. 13; March 28, 2025
(a) Applicability.
(1) This section applies to workers'
compensation insurance and includes employers' liability insurance. Whenever
the term "workers' compensation" is used in this section, the term includes and
applies to employers' liability insurance.
(2) This section applies to each insurance
company authorized to write workers' compensation insurance in the State of
Texas as specified in the Insurance Code §
2053.001(2).
Each insurance company is required to report to the commissioner, or the
commissioner's designated statistical agent, information prescribed by the
commissioner under the Insurance Code §
2053.151 for each
workers' compensation insurance claim.
(b) Purpose. The purpose of this section is
to:
(1) prescribe the reporting requirements
for the information and data to be submitted to the commissioner, or the
commissioner's designated statistical agent, concerning workers' compensation
claims pursuant to the Insurance Code §
2053.151 to ensure
that the data collection methodology will yield data necessary for research and
medical cost containment efforts; and
(2) adopt by reference the
Texas
Detailed Claim Information Statistical Plan, 2010 Edition.(c) Definitions. The following
words and terms when used in this division shall have the following meanings
unless the context clearly indicates otherwise:
(1) Centrally-located--Located in a place
with ready access to the insurance company's claims files and detailed claims
information.
(2) Insurance company,
insurance carrier, insurer, and carrier--Has the same meaning as "Insurance
company" as defined by the Insurance Code §
2053.001(2).
(3) Jurisdiction state--The state responsible
for the claim.
(4) Statistical
Plan--The
Texas Detailed Claim Information Statistical Plan, 2010
Edition adopted by reference pursuant to this section.
(d) Adoption by Reference. The
commissioner adopts by reference the Texas Detailed Claim Information
Statistical Plan, 2010 Edition. The Statistical Plan includes the
rules, requirements, and examples for reporting detailed claim information for
claims with a Reported to Insurer Date of September 1, 2010 and later and
provides reporting instructions, a data dictionary, and claim selection and
sampling methodologies.
(e)
Statistical Plan Availability. The Statistical Plan is published by the Texas
Department of Insurance and is available from the Data Services Division, Mail
Code 105-5D, Texas Department of Insurance, P.O. Box 149104, Austin, Texas
78714-9104 or the department's website at www.tdi.state.tx.us.
(f) Reporting Requirements.
(1) The Statistical Plan specifies the
requirements for reporting claims data, including:
(A) criteria for determining which claims to
report;
(B) data elements and
record layouts for the information that must be reported on each
claim;
(C) standards and procedures
for categorizing insurance and medical benefits required to be reported on each
claim;
(D) information to be used
for determining the specific loss valuation levels for each claim, which
requires it to be reported; and
(E)
instructions regarding how and when to report required data on
claims.
(2) Each
insurance company is required to comply with the reporting requirements of the
Statistical Plan pursuant to the Insurance Code §
2053.151. Each
insurance company must submit required information and data on each claim to
the commissioner, or the commissioner's designated statistical agent, no later
than three months after the loss valuation dates specified in the Statistical
Plan.
(g) Claims
Required to be Reported. A claim's eligibility for reporting is based on an
incurred indemnity loss value greater than zero. Even if no income benefit
payments have been made, but reserves have been set on the claim in
anticipation of payment, the claim is still eligible to be reported. The
following claims must be reported:
(2) lifetime income benefit
claims (i.e., permanent total disability claims);
(3) other open indemnity claims;
and
(4) closed claims selected in
accordance with the sampling method outlined in the Statistical Plan adopted
under this section.
(h)
Claims Excluded from Reporting. The following claims are not required to be
reported:
(1) claims where the jurisdiction
state is not Texas;
(2) claims in
which income benefits have not yet accrued or been paid (i.e., medical only
claims);
(3) losses paid to another
insurance company because of reinsurance assumed by the reporting insurance
company; and
(4) claims that
involve benefits payable under federal workers' compensation laws.
(i) Designated Carrier
Coordinator. Each insurance company must designate one individual as the
coordinator for claims reporting within its organization and provide the
coordinator's contact information, including the coordinator's name, working
title, mailing address, e-mail address, and telephone number, to the
commissioner, or the commissioner's designated statistical agent.
(1) The designated carrier coordinator must:
(A) be a centrally-located employee of the
insurance company who has responsibility for claims, statistical, or data
management;
(B) receive and
appropriately disperse data reporting information received from the
commissioner, or the commissioner's designated statistical agent; and
(C) serve as central compliance control for
data reporting under the Statistical Plan.
(2) An insurance company authorized to write
workers' compensation insurance in this state as of the effective date of this
section must provide the coordinator's contact information required by this
subsection to the commissioner, or the commissioner's designated statistical
agent, no later than September 1, 2010. Except as otherwise provided by this
subsection, an insurance company that obtains a certificate of authority to
write workers' compensation insurance in this state after September 1, 2010,
must provide the coordinator's contact information required by this subsection
to the commissioner, or the commissioner's designated statistical agent, no
later than the 30th day after the insurance company's certificate of authority
becomes effective.
(3) An insurance
company must report any changes to the designated insurance company
coordinator's contact information to the commissioner, or the commissioner's
designated statistical agent, not later than 30 days after the effective date
of the change.
(j)
Effective Date.
(1) This section is effective
on September 1, 2010.
(2) Claims
with a Reported to Insurer Date of September 1, 2010 and later must be reported
in accordance with the Statistical Plan. Claims with a Reported to Insurer Date
prior to September 1, 2010 must be reported in accordance with the
Texas Detailed Claim Information Statistical Plan effective
January 1, 1997 up to and including reports due April 30, 2014.
